Guiding Principles for the Development of Quality Affordable by myx17334

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									                Guiding Principles for the
January, 2008
                Development of Quality
                Affordable Dental Coverage
                Based on Evidence




                 Task Force on Evidence-based
                 Dental Coverage




www.ahip.org
                           Table of ConTenTs


                           Task Force Members and AHIP Staff                          2


                           Letter from the Chair                                      3


                           Introduction                                             4


                           Definitions                                              5


                           Standards of evidence                                     6


                           Guiding principles                                         6


                           Relationship between dental coverage, policies
                           and dental practice                                        7


                           Recommendations                                        7


                           Appendix A Oral health system                             10


                           Appendix B Clinical practice guideline development
                                       and inclusion criteria                           11


                           Appendix C Categorizing evidence                          14


                           Appendix D Sample model for internal structures
                                       and processes to facilitate evidence-based
                                       dental coverage and policy development            15




Task Force on Evidence-Based Dental Coverage · America’s Health Insurance Plans                                                       1
    Task forCe MeMbers

    Dr. Michael Weitzner, Chair (UnitedHealthcare Dental)

    Dr. Robert Compton, Principal Author (Delta Dental of Massachusetts)

    Dr. Max Anderson (Delta Dental Plans Association)

    Cindy Cady, ALHC, HIA, MHP (Principal Financial Group)

    Dr. Paul Chaitkin (Guardian/First Commonwealth)

    Dr. Mary Lee Conicella (Aetna Dental)

    Dr. Tim Custer (Dental Networks of America)

    Susan Emmett (Blue Cross & Blue Shield of Tennessee)

    Dr. Christina Gore, DMD, FAGD

    Dr. Jim Gowan (HealthPartners)

    Dr. Miles Hall (CIGNA Dental)

    Dr. Michael Hahn (CIGNA Dental)

    Dr. George Koumaras (Delta Dental of Virginia)

    Dr. Richard Klich (United Concordia)

    Dr. Bill TenPas (Oregon Dental Service – Delta Dental of Oregon)

    Dr. Alan Vogel (MetLife)


    aHIP sTaff

    Dr. David Wesley (Consultant/America’s Health Insurance Plans)

    Tom Meyers (America’s Health Insurance Plans)




2                                     Guiding Principles for the Development of Quality Affordable Dental Coverage Based on Evidence
                           leTTer froM THe CHaIr


                           Since the publication in 1996 of Dr. David Sackett’s landmark paper, “Evidence Based
                           Medicine: What It Is and What It Isn’t,” the trend toward understanding and incorporating
                           evidence-based methods has moved from clinical medicine alone into most other clinical
                           fields and into a diverse array of related disciplines, such as public health, health policy,
                           health promotion, research, quality assurance, clinical education and even clinical licensure.
                           Dentistry, led by its academic institutions, specialty societies, and the American Dental
                           Association (ADA), has also worked to adopt evidence-based approaches, and we have
                           begun to see the impact these changes are having on dental practice.

                           In 2006, America’s Health Insurance Plans (AHIP), in partnership with its member den-
                           tal carriers, formed the Task Force on Evidence-based Dental Coverage (the task force).
                           The task force’s purpose was to define “Evidence Based Dental Coverage” and develop
                           core principles and recommendations for consideration by dental insurance companies on
                           an individual basis. In fulfilling this purpose, the task force was to develop a meaningful
                           framework for use in this process.

                           The task force hopes that each dental insurance company will carefully consider the prin-
                           ciples offered as it decides upon its own approach to evidence-based dental coverage and
                           policies. The task force also hopes that those of you outside the dental insurance industry,
                           but with an interest in our work, find this informative.


                           Warmest regards,




                           Michael D. Weitzner, DMD, MS

                           Chair, AHIP Task Force on Evidence-Based Dental Coverage




Task Force on Evidence-Based Dental Coverage · America’s Health Insurance Plans                                             3
InTroduCTIon                                                                          A     Create partnerships with the appropriate stakeholders to
Oral health is an important component of the overall health care                            encourage adoption of clinical practice guidelines that are
system. But studies continue to demonstrate wide practice varia-                            based on the highest level of evidence.
tions, inconsistent quality outcomes, and safety issues. Necessary
                                                                                      A     Suggest strategies that advance evidence-based decision-
change will only occur if we engage all stakeholders and seek
                                                                                            making.
solutions that support care that is safe, effective, patient-centered,
timely, efficient, and equitable.1 To achieve these goals, the dental            The task force believes that consumers should receive clinically-ap-
profession and the dental benefits industry should strive to incorpo-            propriate and cost-effective care that is based, to the greatest extent
rate evidence into health care and health care coverage decisions.               possible, on the highest level of evidence. To achieve that goal the
                                                                                 task force offers the following:
The primary objective of this paper is to provide guidance that
can be used by dental benefit plans as each decides how to move                       A     Examples of nationally-recognized standards of evidence;
toward a more evidence-based approach to designing coverage and
                                                                                      A     Guiding principles to aid individual companies in devel-
policies. Additionally, we would expect to see overall improvement
                                                                                            oping criteria to translate scientific evidence into dental
in oral health as the oral health profession continues to implement
                                                                                            coverage and policies; and
evidence-base clinical guidelines.
                                                                                      A     Recommendations for individual companies to consider
“Evidence-based decision-making” is a process that is being used
                                                                                            when adopting policies in support of an evidence-based
with increasing frequency in the health care sector to improve the
                                                                                            approach.
quality of care. To date, however, there has been limited consensus
on principles for applying this approach to oral health care decisions           It is the hope of the task force that dental benefits administrators
or to oral health care coverage and policy decisions, or how evi-                and dental practitioners will use this information to help make
dence-based decision-making could more efficiently and effectively               dental care and dental coverage decisions more evidence-based. It
impact oral health.                                                              is believed that doing so will lead to improved patient health out-
                                                                                 comes and more affordable oral health care.
To address this need, the Dental Committee of America’s Health
Insurance Plans (AHIP) chartered a task force to conduct research
and publish a position paper with its recommendations to further
advance evidence-based decision making in oral health. Specifically,
the task force was asked to:

      A    Provide guidance to dental benefit companies on how to
           identify which dental services are based on the highest
           level of available evidence; where gaps in evidence exist;
           and how the evidence or gaps impact those services and
           related oral health coverage and policies.

      A    Provide examples of nationally-recognized standards for
           evaluating evidence.

      A    Develop guiding principles to aid individual companies in
           translating evidence into oral health coverage and policies.




1
     IOM, Crossing the Quality Chasm, 2001, National Academy of Science, Pgs.
    39-40.


4                                                                   Guiding Principles for the Development of Quality Affordable Dental Coverage Based on Evidence
defInITIons                                                                       of “evidence-based dentistry.” To begin the conversation, the task
The Task Force believes that using clearly understood terms is criti-             force recommends focusing on the following definitions:
cal to achieving a better understanding of how evidence can be used
                                                                                          A Evidence-based Dental Coverage3
to lead to better coverage and policy decisions and better patient care
                                                                                        [Evidence based dental coverage determinations are based on]
and satisfaction. In working towards such an understanding, the task
                                                                                        a set of principles and methods intended to ensure that to the
force recognized that oral health care is part of a broader oral health
                                                                                        greatest extent possible, medical [and dental] decisions, guide-
system (see Appendix A – Oral Health System) in which there are
                                                                                        lines, and other types of policies are based on and consistent
many stakeholders that have a significant impact on oral health.
                                                                                        with good evidence of effectiveness and benefit. 4
It is important to distinguish between a clinical practice guideline,
                                                                                          A Evidence-based Dentistry (EBD)5
which addresses health care decisions, and a coverage guideline,
                                                                                        “An approach to oral health that requires the judicious integra-
which addresses coverage decisions. Both of these decision areas
                                                                                        tion of systematic assessments of clinically relevant scientific
are important and will present opportunities for evidence-based
                                                                                        evidence, relating to the patient’s oral and medical condi-
dentistry and evidence-based dental coverage to interface.
                                                                                        tion and history, with the dentist’s clinical expertise and the
In choosing definitions to highlight, the task force looked to key                      patient’s needs and preference.”
nationally recognized work pertaining to evidence-based care, levels
                                                                                          A Clinical Practice Guideline6
of evidence, and practice guidelines created by others in the health
                                                                                        Clinical practice guidelines are systematically developed state-
care sector, such as, the American Dental Association (ADA) defini-
                                                                                        ments to assist practitioner and patient decisions about appro-
tion of evidence-based dentistry and a definition of evidence-based
                                                                                        priate health care for specific clinical circumstances.
medicine put forth by Dr. David Eddy2 that is gaining acceptance
in the medical community.                                                                 A Evidence-based Coverage Guideline
                                                                                        Evidence-based coverage guidelines are systematically developed
The Task Force acknowledges the American Dental Association’s
                                                                                        statements that are based on the best available evidence and
work in defining evidence-based dentistry, and includes this defini-
                                                                                        intended to assist dental benefit plans and purchasers in choos-
tion, because of the significant interaction and interdependence
                                                                                        ing appropriate coverage to meet the clinical needs of the mem-
of an evidence-based approach between the design of oral health
                                                                                        bers while providing an affordable benefit package.
coverage and policies and patient treatment. Additionally, the Task
Force modified Dr. Eddy’s definition for use as the Evidence-based                All stakeholders, in both the dental insurance industry and the oral
Dental Coverage definition. It is important to develop such a com-                health profession, have an interest in identifying high-quality, strong
mon understanding of evidence-based terms by the various stake-                   scientific evidence that supports effective treatments for oral disease
holders (payers, providers, researchers, etc.) to maintain a consensus            and in seeking evidence that a particular treatment is effective in
throughout medicine, dentistry and oral health.                                   preventing or treating disease prior to considering any other factor
                                                                                  when designing a benefit plan or the treatment plan.
Finally, the task force recognizes that each stakeholder (referenced in
Appendix A) within the “oral health system” makes a unique con-
tribution to oral health and that input from, and consensus among,
these stakeholders is needed to advance a common understanding

                                                                                  3
                                                                                      Definition is modified from: DM Eddy, Evidence-Based Medicine: A Unified
                                                                                      Approach. Health Affairs. Vol. 24 No 1. Jan/Feb 2005.
                                                                                  4
                                                                                      According to Eddy the term “policies” includes such things as benefit
2
     David Eddy MD Ph.D. is the founder and medical director of Archimedes            coverage, disease management, performance measures, quality improvement,
    Inc. in Aspen, Colorado, Archimedes was founded to improve the quality            medical necessity, regulations, public policy, etc.: A Unified Approach. Health
    and efficiency of health care by using advanced mathematics and computing         Affairs. Vol. 24 No 1. Jan/Feb 2005.
    methods to build realistic simulation models of physiology, diseases, and     5
                                                                                      Source: The American Dental Association.
    health care systems. Eddy has made seminal contributions to evidence-based    6
                                                                                       Institute of Medicine. (1990). Clinical Practice Guidelines: Directions for
    medicine, coining the term “evidence based” and applying it to guidelines,        a New Program, M.J. Field and K.N. Lohr (eds.) Washington, DC: National
    coverage policies, and performance measures.                                      Academy Press. page 38.


Task Force on Evidence-Based Dental Coverage · America’s Health Insurance Plans                                                                                    5
sTandards of evIdenCe                                                        effectiveness refers to the impact under normal or usual circum-
Not all evidence is equal. The scientific community has developed            stances in the real world while efficacy refers to the impact of an
methods to help distinguish high-quality, sound evidence that has            intervention in a controlled clinical trial environment, which may or
undergone rigorous validation processes (Appendix B) from lower-             may not translate to the real world.
quality, weaker evidence.
                                                                             Efficient: avoiding waste, including waste of equipment, supplies,
Recognizing these differences, the task force recommends that when           ideas and energy.10 Efficiency is assessed by considering resource use
determining the level of evidence with respect to the quality and            and those services that yield limited dental benefit and/or needlessly
strength of research findings, an unbiased rating system should be           waste consumer dollars.
used that is:
                                                                             Cost-benefit: Cost-benefit analysis measures the costs and benefits
      A     Developed by a recognized, credible professional organiza-       of a proposed course of action in terms of the same units, usually
            tion or institution (such as Shekelle’s, the US Preventive       monetary units.11 For example, a cost-benefit analysis of periodon-
            Services Task Force, or the Oxford Centre for Evidence-          tal treatment would determine the number of dollars spent toward
            based Medicine, The Cochrane Collaboration – see                 saving teeth through periodontal treatment. It would then deter-
            Appendix C for an example of a classification scheme and         mine the number of dollars saved because the patient would not
            links for additional information).                               need extractions, or other dental treatment related to the loss of the
                                                                             teeth. Another important measurement unit is quality of life, which
      A     Transparent and publicly available so that all interested
                                                                             should also be considered.
            parties may review and understand the criteria and rating
            system used.                                                     Cost-effective: the minimal expenditure of dollars, time, and other
                                                                             elements necessary to achieve the health care result deemed neces-
In addition, where a rating score has been assigned to research
                                                                             sary and appropriate.12 For example, a cost-effectiveness analysis
studies or peer reviewed literature it should be publicly available so
                                                                             could compare the costs (in units such as dollars or quality of life)
that all interested parties can easily access the material. The system
                                                                             of replacing missing teeth with removable prosthetics versus fixed
should be clear enough to be understood by employers, as well as
                                                                             prosthetics or dental implants.
dental consumers.
                                                                             Each dental benefit plan should consider ways to design coverage

GuIdInG PrInCIPles                                                           and policies to make the best use of the highest level of available

The task force recommends the use of the following principles to             evidence for coverage determinations. In addition, individual dental

aid in developing criteria to translate scientific evidence into dental      benefit plans should consider, consistent with the plan’s procedures

coverage and policies.                                                       and policies, ways to best provide practitioners with an explanation
                                                                             of, and opportunity to appeal, a denial of coverage or payment,
Effectiveness: the degree to which action(s) achieves the intended           when such denial is based on the plans understanding of highest
health result under normal or usual circumstances.7 The Institute            level of evidence currently available.
of Medicine defines effective care as “providing services based on
scientific knowledge to those who could benefit and refraining from
providing services to those not likely to benefit (avoiding underuse
and overuse, respectively)”.8

Efficacy: the ability to provide a clinically measurable effect, prefer-
ably beneficial.9 Scientific evidence should demonstrate a beneficial
efficacy. From an epidemiological perspective, the difference is that

                                                                             10
                                                                                  Ibid
7
    Mosby’s Dental Dictionary. Mosby, Inc., St. Louis. 2004                  11
                                                                                  Jekel JF, Elmore JG, and Katz DL. Epidemiology, Biostatistics and Preventive
8
    Crossing the Quality Chasm, Institute of Medicine, 2001                       Medicine. WB Saunders Company. 1996 p. 187
9
    Mosby’s Dental Dictionary. Mosby, Inc., St. Louis. 2004                  12
                                                                                  Mosby’s Dental Dictionary. Mosby, Inc., St. Louis. 2004


6                                                               Guiding Principles for the Development of Quality Affordable Dental Coverage Based on Evidence
relaTIonsHIP beTween denTal CoveraGe,                                             reCoMMendaTIons
PolICes and denTal PraCTICe                                                       To help drive the benefit determinations and the practice of dental
Both the dental benefits sector and the dental care delivery system               care towards being more evidence-based, a process must be created
are striving to become more evidence-based, to advance services that              to both identify high-quality evidence and translate that evidence
result in the best patient outcomes and maintain affordability. It is             into useful and relevant guidelines. The task force recommends
important that patients receive care based on sound scientific evi-               the following process to further advance the movement toward the
dence that supports both its clinical and cost effectiveness, and that            highest level of evidence-based decisions in dental coverage and
dental benefits are aligned to support such care. In achieving this               policies and dental practice:
goal, clinical guidelines are a logical focal point for dental benefits
                                                                                      1. IdentIfyIng evIdence
providers and the dental delivery system. This focus on guidelines
promotes interaction and cooperation in aligning treatment and                        To transition to an evidence-based dental benefit structure,
financial incentives to achieve the best health and financial out-                    entities such as dental benefit plans, dental associations, and
comes for dental plan members and patients.                                           employer groups, should have a process in place to identify and
                                                                                      assess the research with respect to quality and cost effectiveness
The National Guideline Clearinghouse (NGC) serves both as an
                                                                                      or contract with entities that have that capacity.
example of how key stakeholders can interface and work coopera-
tively on evidence-based initiatives and as a resource for clinical                   2. Access to evIdence
guidelines that can be used to advance evidence-based dental care
                                                                                      The task force recommends that the National Guideline
coverage and treatment decisions. NGC was created as a joint effort
                                                                                      Clearinghouse be considered as the place for evidence to be
of the American Medical Association, the American Association
                                                                                      accessed, and coordinate with other interested parties to make
of Health Plans (now America’s Health Insurance Plans [AHIP])
                                                                                      sure that the data bases remain easily accessible, reliable, and
and the Agency for Healthcare Research and Quality (AHRQ) of
                                                                                      widely available.
the U.S. Department of Health and Human Services. In existence
since 1998, the NGC is a Web-based database of evidence-based                         clInIcAl prActIce guIdelInes
clinical practice guidelines, including several related to oral health,               Consideration should be given for the development of clinical
and related documents, maintained as a public resource by AHRQ.                       practice guidelines wherever the scientific evidence indicates
NGC’s mission is to provide physicians, nurses, and other health                      that treatment variability can be reduced and lead to improved
professionals, health care providers, health plans, integrated delivery               health outcomes and cost-effectiveness. The task force is cur-
systems, purchasers, and others an accessible mechanism for obtain-                   rently discussing with the NGC ways to increase the availability
ing objective, detailed information on clinical practice guidelines                   of dental evidence-based guidelines.
and to promote the dissemination, implementation, and use of the
clinical guidelines.                                                                  4. reseArch Assessments And guIdelIne
                                                                                         development
AHIP encourages qualified organizations to continue to use scien-
tific evidence to create clinical guidelines related to dental treatment              Once evidence has been identified, evaluated for quality and

and post them at this Web site. It also encourages dental benefit                     strength, and used to create a clinical guideline, the National

plans to review and consider these guidelines when modifying their                    Guideline Clearinghouse process should be followed to deter-

existing dental benefits or creating new plan designs.                                mine whether the guideline merits public posting. In this pro-
                                                                                      cess, dental benefit plans should actively participate as part of
                                                                                      a multi-stakeholder workgroup that would apply specific, pre-
                                                                                      defined, transparent criteria to evaluate the guideline evidence
                                                                                      in the areas of clinical effectiveness, cost-benefit analysis, and
                                                                                      cost-effectiveness. Approved guidelines will be publicly avail-
                                                                                      able on the National Guideline Clearinghouse database.



Task Force on Evidence-Based Dental Coverage · America’s Health Insurance Plans                                                                            7
    5. AlIgnIng evIdence-bAsed dentAl
      treAtment And reImbursement

    Dental benefit plans may consider further aligning their reim-
    bursement methodology and other financial incentives to pro-
    mote the most clinically and cost-effective treatment based on
    the best available scientific evidence and consistent with their
    own product designs, client needs and demands, market and
    regulatory environments and other company-specific factors.

    6. InternAl structures And processes

    Dental benefit plans that adopt an evidence-based approach
    should examine their internal structures and processes to
    determine if they have the necessary capabilities to gather and
    evaluate scientific evidence to use in designing dental benefits,
    policies, and reimbursement and incentive methodologies.
    An example of such structures and processes is provided in
    Appendix D.




8                                                             Guiding Principles for the Development of Quality Affordable Dental Coverage Based on Evidence
aPPendICes


A. Oral Health System

B. Clinical Practice Guideline Development and Inclusion Criteria

C. Categorizing Evidence

D. Sample Model for Internal Structures and Processes to Facilitate
    Evidence-Based Dental Coverage and Policy Development




Task Force on Evidence-Based Dental Coverage · America’s Health Insurance Plans   9
aPPendIx a: oral HealTH sysTeM


                                                  the oral health system**




         (**The above AHIP graphic is not meant to be an exhaustive list of all the stakeholders within the oral health system)




10                                                        Guiding Principles for the Development of Quality Affordable Dental Coverage Based on Evidence
aPPendIx b. ClInICal PraCTICe GuIdelIne develoPMenT and InClusIon CrITerIa

  NatioNal GuiDEliNE ClEariNGhousE
  this information was obtained from the following Web site: http://www.guideline.gov/resources/glossary.aspx

MeTHod of GuIdelIne valIdaTIon                                                    A Meta-analysis of individual patient data
A Clinical validation-pilot testing/clinical validation-trial imple-                 A meta-analysis that combines and synthesizes data collected
   mentation period                                                                  from individual patient data (versus summary statistics).
     These methods “test drive” the recommendations in an actual
                                                                                  A Meta-analysis of observational trials
     clinical setting. The information obtained during the pilot test-
                                                                                     A meta-analysis that combines and synthesizes data collected
     ing or initial implementation period is incorporated back into
                                                                                     from observational studies (e.g., a cross-sectional study, a case
     the guidelines in an attempt to improve their utility in actual
                                                                                     series, a case-control study, or a cohort study), versus a random-
     practice.
                                                                                     ized controlled trial.
A Comparison with guidelines for other groups
                                                                                  A Meta-analysis of randomized controlled trials
   The process whereby the guideline developer compares their
                                                                                     A meta-analysis that combines and synthesizes data collected
   recommendations to those issued by different groups as a way of
                                                                                     from randomized controlled trials (i.e., clinical trials that involve
   gauging the validity of their guideline. The authors may explain
                                                                                     at least one test treatment and one control treatment, concurrent
   conflict or agreement with guidelines for the same health prob-
                                                                                     enrollment and follow-up of the test- and control-treated groups,
   lem from other organizations.
                                                                                     and in which the treatments to be administered are selected by a
A External peer review                                                               random process, such as the use of a random-numbers table).
   The process whereby the guideline is evaluated by reviewers
                                                                                  A Meta-analysis of summarized patient data
   that do not belong to the same organization that developed the
                                                                                     A meta-analysis that combines and synthesizes data collected
   guideline.
                                                                                     from summarized patient data (versus individual patient data or
A Internal peer review                                                               summary statistics).
   The process whereby the guideline is evaluated by reviewers that
                                                                                  A Review
   belong to the same organization that developed the guideline.
                                                                                     A summary of published material on a subject. It may be com-
A Peer review                                                                        prehensive to various degrees and the time range of material
   The process to evaluate or audit the relevance, appropriateness,                  scrutinized may be broad or narrow. The conclusions of a review
   validity, or utility of the final guideline recommendations.                      are often combined qualitatively with little, if any, quantitative
                                                                                     manipulation of the published information.

MeTHods used To analyze THe evIdenCe                                              A Review of published meta-analyses
A Decision analysis                                                                  A summary of published meta-analyses on a subject.
   A quantitative method for representing and comparing the
                                                                                  A Systematic review
   expected outcomes of management alternatives.
                                                                                     A review of a clearly formulated question that uses systematic
A Meta-analysis                                                                      and explicit methods to identify, select and critically appraise rel-
   A quantitative method of combining and synthesizing the                           evant research, and to collect and analyze data from studies that
   results of multiple independent studies (usually drawn from the                   are included with the review.
   published literature) to arrive at conclusions about a body of
                                                                                  A Systematic review with evidence tables
   research.
                                                                                     A systematic review that utilizes a tabular compilation of the data
                                                                                     from individual studies.




Task Force on Evidence-Based Dental Coverage · America’s Health Insurance Plans                                                                           11
MeTHods used To assess THe QualITy and                                       MeTHods used To ColleCT/seleCT THe evIdenCe
sTrenGTH of THe evIdenCe                                                     A Hand searches of published literature (primary sources)
A Expert consensus                                                               Methods based on a manual review (i.e., page-by-page) of lit-
     A formal method used to generate expert collective decisions.               erature sources that report original research (e.g., peer-reviewed
     The steps in the process are made explicit and could be repli-              journal articles).
     cated.
                                                                             A Hand searches of published literature (secondary sources)
A Expert consensus (committee)                                                   Methods based on a manual review (i.e., page-by-page) of lit-
     A formal method involving a dedicated committee to generate                 erature sources that synthesize and summarize the theories and
     expert collective decisions. The steps in the process are made              results of research (e.g., textbooks, monographs, review articles).
     explicit and could be replicated.
                                                                             A Searches of electronic databases
A Expert consensus (Delphi method)                                               Methods that employ the use of free-text keywords/phrases and/
     A formal method used to generate expert collective decisions.               or controlled vocabularies to identify information contained
     The steps in the process are made explicit and could be repli-              within computer-based repositories of information (e.g., biblio-
     cated. In the Delphi method, participants receive questionnaires            graphic, full-text).
     and record their views. The responses are aggregated by the orga-
                                                                             A Searches of patient registry data
     nizers and sent back to participants in summary form, indicating
                                                                                 Methods that employ the use of repositories of patient-specific
     the group judgment and the individual’s initial judgment. The
                                                                                 data maintained by sources such as medical specialty societies,
     participants are given the opportunity to revise their judgments,
                                                                                 disease-specific associations, government agencies, and manufac-
     and the process may be repeated. In this method, the partici-
                                                                                 turers are accessed.
     pants never meet face-to-face or interact directly.
                                                                             A Searches of unpublished data
A Subjective review
                                                                                 Methods that employ the use of data that has not been pub-
     A process of review relying on the use of an individual’s or
                                                                                 lished (e.g., proprietary data, unpublished manuscripts, data
     group’s experience or knowledge, as conditioned by personal
                                                                                 from ongoing research).
     mental characteristics or states. This method uses a descriptive
     (qualitative) approach rather than a quantitative and/or numeri-
     cal method to evaluate the quality and strength of evidence.

A Weighting according to a rating scheme
     This method consists of using a system that assigns a weighted
     value (e.g., levels or grades) to distinguish high from low qual-
     ity research studies and/or strong from weak bodies of evidence.
     Systems have been developed for studies/evidence pertaining to
     therapy, prevention, diagnosis, prognosis and harm.




12                                                              Guiding Principles for the Development of Quality Affordable Dental Coverage Based on Evidence
MeTHods used To forMulaTe THe                                                     CrITerIa for ClInICal PraCTICe GuIdelIne To be
reCoMMendaTIons                                                                   PosTed To nGC
A Balance sheets                                                                  All of the criteria below must be met for a clinical practice guideline
   A tool used in clinical decision-making capturing the benefits,                to be included in NGC.
   harms and costs of different interventions. Information to com-
                                                                                     1.   The clinical practice guideline contains systematically devel-
   plete the sheet is obtained from data in medical literature, local
                                                                                          oped statements that include recommendations, strategies,
   organizational data or best estimates when data is of low quality
                                                                                          or information that assists physicians and/or other health
   or unknown.
                                                                                          care practitioners and patients to make decisions about
A Expert consensus                                                                        appropriate health care for specific clinical circumstances.
   A parent term identifying recommendations formulated by one                       2.   The clinical practice guideline was produced under the
   of several formal consensus development methods.                                       auspices of medical specialty associations; relevant profes-
A Expert consensus (Consensus development conference)                                     sional societies, public or private organizations, government
   A selected group of around ten people is brought together to                           agencies at the Federal, State, or local level; or health care
   reach consensus about an issue in an open meeting. Evidence is                         organizations or plans. A clinical practice guideline devel-
   presented by various groups/experts that are not part of the deci-                     oped and issued by an individual not officially sponsored or
   sion-making group and the selected group retreats to consider                          supported by one of the above types of organizations does
   the issue and evidence.                                                                not meet the inclusion criteria for NGC.

                                                                                     3.   Corroborating documentation can be produced and veri-
A Expert consensus (Delphi method)
                                                                                          fied that a systematic literature search and review of existing
   Participants receive questionnaires and record their views. The
                                                                                          scientific evidence published in peer reviewed journals was
   responses are aggregated by the organizers and sent back to par-
                                                                                          performed during the guideline development. A guideline
   ticipants in summary form, indicating the group judgment and
                                                                                          is not excluded from NGC if corroborating documentation
   the individual’s initial judgment. The participants are given the
                                                                                          can be produced and verified detailing specific gaps in scien-
   opportunity to revise their judgments, and the process may be
                                                                                          tific evidence for some of the guideline’s recommendations.
   repeated. In this method, the participants never meet face-to-face
   or interact directly.                                                             4,   The full text guideline is available upon request in print or
                                                                                          electronic format (for free or for a fee), in the English lan-
A Expert consensus (Nominal group technique)
                                                                                          guage. The guideline is current and the most recent version
   With a purpose of structuring interaction within a group, after
                                                                                          produced. Documented evidence can be produced or veri-
   participants record views independently and privately, the facili-
                                                                                          fied that the guideline was developed, reviewed, or revised
   tator will collect one view from each individual and create a list.
                                                                                          within the last five years.
   All views are collected and listed, and discussion ensues about
   each view. Individuals then privately record their judgments or
   vote for options. Further discussion and voting may take place.
   The individual judgments are aggregated statistically to derive
   group judgment.

A Informal expert consensus
   An approach to consensus development that lacks structure.
   Participants publicly express their views, the aggregate of which
   may be summarized by the group’s leader and considered the
   final decision.




Task Force on Evidence-Based Dental Coverage · America’s Health Insurance Plans                                                                            13
aPPendIx C. CaTeGorIzInG evIdenCe

Systems have been developed to categorize evidence based on its                    links to other credible systems for evaluating evidence:
methods of avoiding various biases that are possible in research and                   A    Oxford Center for Evidence-based Medicine (http://www.
the strength of the evidence. An example of a system of categorizing                        cebm.net/index.aspx?o=1025).
evidence is the following developed by Shekelle, et al :     13
                                                                                       A    U.S. Preventive Service Task Force
Category of evidence (susceptibility to bias):                                              (http://www.ahrq.gov/clinic/uspstfix.htm
     I.a. Evidence from meta-analysis of randomized controlled trials                  A    The Cochrane Collaboration
     I.b. Evidence from at least one randomized controlled trial                            (http://www.cochrane.org/index.htm)
     II.a. Evidence from at least one controlled study without ran-
           domization

     II.b. Evidence from at least one other type of quasi-experimental
           study

     III. Evidence from non-experimental descriptive studies, such
           as comparative studies, correlation studies, and case-control
           studies

     IV. Evidence from expert committee reports or opinions or
           clinical experience of respected authorities, or both

strength of recommendation:
     A. Directly based on category I evidence

     B. Directly based on category II evidence or extrapolated rec-
           ommendation from category I evidence

     C. Directly based on category III evidence or extrapolated rec-
           ommendation from category I or II evidence

     D. Directly based on category IV evidence or extrapolated rec-
           ommendation from category I, II or III evidence
       Reproduced, with permission from the BMJ Publishing Group,
       from BMJ, 1999; 318; 595.




13
      Shekelle PG, Woolf SH, Eccles M, Grimshaw J. Clinical guidelines:
     developing guidelines. BMJ 1999;318 (7183) :593-6.


14                                                                    Guiding Principles for the Development of Quality Affordable Dental Coverage Based on Evidence
aPPendIx d. saMPle Model for InTernal sTruCTures and ProCesses To faCIlITaTe evIdenCe-based
            denTal CoveraGe and PolICy develoPMenT
Developing evidence-based dental coverage and policies is more                    Processes
than just re-labeling products. It can require significant resources                1.   The workgroup may establish a process to identify opportu-
and changes to internal structures and processes. Those dental ben-                      nities to make benefits more evidence-based and to periodi-
efit companies who embark on such a change may want to examine                           cally review new evidence to update existing dental coverage
their own internal structures and processes to determine if they                         and policies.
have the necessary capabilities. The following sample model may
                                                                                    2.   A reporting process may connect the workgroup with the
prove helpful as each company makes its company-specific decisions
                                                                                         decision makers at the highest level, including the Board, to
related to ensuring that it has the necessary structures and processes
                                                                                         give forward looking trend information regarding benefits.
to develop evidence-based dental coverage and policies.
                                                                                    3.   A reporting process may update senior management at regu-
structures                                                                               lar intervals on such topics as:
   1.    Staff
                                                                                         a.   Modification of existing dental plans
         a.      A dedicated employee or consultant with clinical exper-
                                                                                         b.   Financial impact of new therapies
                 tise (e.g., a dentist or hygienist) could be designated to
                 advise management on evidence-based dental coverage                     c.   Need to change utilization review criteria
                 and policies
                                                                                         d.   Need for system upgrades
         b.      Creation of a cross-functional workgroup that serves to
                                                                                         e.   Need to design new dental plans
                 ensure that the plan benefits are and remain evidence-
                 based. The workgroup could include:                                     f.   Need for additions or deletions to the CDT proce-
                                                                                              dure code set working through the American Dental
                 i.    Clinically knowledgeable person (chair)
                                                                                              Association (ADA) Code Revision Committee
                 ii.   An actuary
                                                                                         g.   Need for implementation of diagnostic codes (ties back
                 iii. Marketing/sales/competitive intelligence                                to IT/Ops)
                       individual(s)
                                                                                    4.   A Marketing mechanism may be developed to communicate
                 iv. Information Technology(IT) and Operations                           evidence-based information to purchasers and members so
                       individual(s)                                                     that they can make informed decisions. Marketing is the
                                                                                         link to members and groups.
   2.    Information technology systems could include:
                                                                                    5.   A timely process to update adjudication guidelines and utili-
         a.      Access to databases; and
                                                                                         zation review processes may be considered.
         b.      Analytic capabilities
                                                                                    6.   A timely process to ensure that all quality initiatives and
   3.    Access to library materials and search engines such as                          processes, including credentialing of networks take into
         PubMed and EviDents to do literature reviews.                                   account evidence-based care may be considered.
   4.    Financial support in budget for items such as subscriptions                7.   Companies, while making its individual decisions about all
         to periodicals, attendance at professional meetings, etc.                       reimbursement-related policies, may consider how best to
                                                                                         align financial incentives for providers to encourage adop-
                                                                                         tion of the most efficacious and cost-effective care.




Task Force on Evidence-Based Dental Coverage · America’s Health Insurance Plans                                                                        15

								
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